Thursday, January 18, 2007

The New Jersey Superior Court of Appeals ruled Wednesday in two separate cases that the health insurance program administrator for state workers wrongly denied requests of families who sought autism services including speech and occupational therapy for their young child diagnosed with autism spectrum disorder.

These cases represent legal rulings in one state, and for one group of people (children of state employees), but illustrate a larger skirmish taking place around the country between health insurers who would rather see someone else bear the cost of autism-related services and families who are told such services are an essential path to progress.

You can read the 23-page decision in the case of Jacob Micheletti and Joseph Micheletti v. State Health Benefits Commissionhere (via Rutgers University law library). The gist of the case: the state workers' health insurance administrator violated state law by not providing equal coverage to a person with a "biologically based mental illness" (BBMI) such as autism. The administrator had denied the request for speech and O.T. due to a narrow, "literal" reading of a state law which stated that such services were not required since they were not "restorative" -- that is, they were not designed to bring back abilities the autistic child used to have. Instead, they were designed to foster new abilities.

The appeals court judge, Donald G. Collester, wrote that the state law's spirit "is to afford greater coverage to those afflicted with BBMIs. However, the State Health Benefits Commission's exclusion of treatment for autism eviscerates that purpose." He further wrote:

In this case the denial of coverage for Jake's prescribed treatment is couched in terms of the contractual exclusion of benefits for non-restorative speech, physical and occupational therapy, but the medical evaluations of Jake indicate that the therapy is the only treatment modality for an autistic child. Denial of the treatment amounts to exclusion from coverage of a class of dependents, notably afflicted children, based on the nature of their mental illness, which is beyond the limits of the statutory authority of the SHBC.

The exclusion as applied by SHBC is contrary to the goal of the State Health Benefits Program because it would lead to the anomalous and unacceptable conclusion that while medically necessary treatment for autistic children is mandated for dependents of those insured by "carriers," an unfortunate State employee who has an autistic child must bear the entire cost of necessary treatment in addition to the emotional burden of having a child afflicted by this incurable and mysterious illness. This result runs contrary to the core of the State Health Benefits Act.

In a separate but similar case in which a state employee appealed the denial of health insurance coverage for O.T. services to a child with autism -- after receiving coverage for 22 months worth of services -- Judge Edith K. Payne also ruled in favor of the family. Payne noted that the health insurance administrator decided to preclude coverage for O.T., speech and physical therapy for children with autism and Pervasive Developmental Disorder "after a rise in such claims had been recognized" by its medical director.

This case is called Walter Markiewicz v. State Health Benefits Commission, and you can see the 19-page ruling here.

New Jersey state officials today were figuring out whether they were going to appeal the rulings, according to a newspaper report online in The Courier Post, based in the southern part of the state.